Both for individuals and for a population of individuals, health determinants include the physical environments in which people live and work; their behaviors; their biology (genetic makeup, family history, and physical and mental health problems acquired during life); a host of social factors that include economic circumstances, socioeconomic position, and income distribution; discrimination based on factors such as race/ethnicity, gender, or sexual orientation and on the availability of social networks or social support; and the health services to which they have access (Blum 1983; Evans, Barer, and Marmor 1994; Berkman and Kawachi 2000).
Healthy People 2010 (www.healthypeople.gov) is a report that details comprehensive national health promotion and disease prevention agendas. The following list of health determinants is adapted from its identification and definition of determinants (U.S. DHHS 2000):
• Biology refers to the individual's genetic makeup (those factors with which he or she is born), family history (which may suggest risk for disease), and the physical and mental health problems acquired during life. Aging, diet, physical activity, smoking, stress, alcohol or illicit drug abuse, injury or violence, or an infectious or toxic agent may result in illness or disability and can produce a "new" biology for the individual.
• Behaviors are individual responses or reactions to internal stimuli and external conditions. Behaviors can have a reciprocal relationship to biology; in other words, each can react to the other. For example, smoking (behavior) can alter the cells in the lung and result in shortness of breath, emphysema, or cancer (biology), which then may lead an individual to stop smoking (behavior). Similarly, a family history that includes heart disease (biology) may motivate an individual to develop good eating habits, avoid tobacco, and maintain an active lifestyle (behaviors), which may prevent his or her own development of heart disease (biology).
Personal choices and the social and physical environments surrounding individuals can shape behaviors. The social and physical environments include all factors that affect the life of individuals— positively or negatively—many of which may not be under their immediate or direct control.
• Social environment includes interactions with family, friends, coworkers, and others in the community. It also encompasses social institutions such as law enforcement, the workplace, places of worship, and schools. Housing, public transportation, and the presence or absence ofviolence in the community are among other components of the social environment. The social environment has a profound effect on individual health, as well as on the health of the larger community, and is unique because of cultural customs; language; and personal, religious, or spiritual beliefs. At the same time, individuals and their behaviors contribute to the quality of the social environment.
• Physical environment can be thought of as that which can be seen, touched, heard, smelled, and tasted. However, the physical environment also contains less tangible elements such as radiation and ozone. The physical environment can harm individual and community health, especially when individuals and communities are exposed to toxic substances; irritants; infectious agents; and physical hazards in homes, schools, and work sites. The physical environment also can promote good health, for example, by providing clean and safe places for people to work, exercise, and play.
• Policies and interventions can have a powerful and positive effect on the health of individuals and the community. Examples include health promotion campaigns to prevent smoking; policies mandating child restraints and safety belt use in automobiles; disease prevention services such as immunization of children, adolescents, and adults; and clinical services such as enhanced mental health care. Policies and interventions that promote individual and community health may be implemented by a variety of agencies, such as transportation, education, energy, housing, labor, justice, and other venues, or through places of worship, community-based organizations, civic groups, and businesses.
• Quality health services can be vital to the health of individuals and communities. Expanding access to services is important to eliminate health disparities and to increase the quality and years of healthy life for all people living in the United States. Health services in the broadest sense include not only services received through health services providers but also health information and services received through other venues in the community.
When considering health in regard to individuals or populations, it is important to remember that people vary along many dimensions, including their health and health-related needs. The citizenry of the United States is remarkably diverse, varying by age, gender, race/ethnicity, and other factors. As Census 2000 revealed, of a total population of 281.4 million people, about 35 million were over the age of 65, and about 17 million of those were over 75 years of age (U.S. Census Bureau 2000). By 2020, these numbers will increase to about 55 million and 23 million, respectively (U.S. DHHS 2004). These demographic changes are important when considering health and its pursuit, because older people consume relatively more health services and their health-related needs differ in significant ways from those of younger people. Older people are more likely to consume long-term-care services and community-based services intended to help them cope with various limitations in the activities of daily living.
In Census 2000, approximately 34 million African Americans and 35 million Latinos were included in the U.S. population total of 281.4 million (U.S. Census Bureau 2000). Each group represented more than 12 percent of the total population. Both groups are presently disproportionately under-served for health services and are underrepresented in all of the health professions. They experience discrimination that affects their health and, as is described in The Real World of Health Policy: Race, Ethnicity, and Health Care, these and other minority populations experience continuing disparities in the burden of illness and death (Krieger 2000; Henry J. Kaiser Family Foundation 2003).
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